Elective Care Reform : Alternatives to Referral - PowerPoint Presentation

Slide1

Elective Care Reform : Alternatives to ReferralNovember 2018

Dr Karen McEwan

Planned Care Lead SCCG

Karen Moran

Senior Commissioner Planned Care SCCG

Andrea Stewart

Senior Transformation Programme Manager SNHSFT

Agenda

WELCOME AND INTRODUCTION  

REGIONAL AND LOCAL

CONTEXT

ALTERNATIVES

TO REFERRAL

Advice & Guidance

Tele-Dermatology

Effective Use of Resources – procedures of limited clinical benefit

Community Services

Patient Education – classes and webinars

Faecal

Immunochemical

Testing (FIT)

Q & A

session

Regional Context

GM Elective Care Programme

PRE-REFERRAL

Shared Decision Making

Effective Use of Resources Compliance

Advice & Guidance (A&G)

REFERRAL

E-Referral System (

eRS

)

Standardised Referral Template

Referral Triage

Local Context –

Stockport Together Outpatients Redesign

Stockport Together Priorities

PRIORITY 1:

Active support for patients to enable them to take more control of their condition

PRIORITY 2:

Support for GPs in clinical decision making

PRIORITY 3:

Appropriate clinical triage of referrals and diagnostics

PRIORITY 4:

Alternative mechanisms for traditional appointments

PRIORITY 5:

Identifying outpatient activity that can be stopped

PRIORITY 6:

Coordinated support for complex patients

Support for GPs to clinical decisions via Advice and Guidance

National & Regional Drive via the Advice

& Guidance CQUIN

and GM Elective Care Programme

Advice and Guidance is already happening across many specialties in either adhoc / informal ways eg

. email, letter, phone, fax

Lower GI, Upper GI, Urology, Rheumatology, Gynaecology, Community Diabetes, Acute Medicine, Obstetrics, Chest

Change is to introduce more structured, systematic and reliable approaches

Verbal – Consultant Connect

Live in 7 specialties

Cardiology

Haematology

PaediatricsGastro – generalGastro – IBDDiabetes & Endocrinology

ENT

Opportunities to extend to other specialties are being exploredWritten – e-Referral System (

eRS)Planned roll-outDiabetes & Endocrinology – already availableLipids – already availableGynaecology – planned

General Surgery – plannedFurther roll-out planned over coming months

Tele-Dermatology10 practices are piloting the system since January 2018

WE ARE ROLLING THIS OUT ACROSS

STOCKPORT

Total Referrals

203

Responded on the same day

86.3%

Outcomes

Advice only

142

70%

OP appointment

34

17%

Rejected

27

13%

(Rejection reasons)

Inadequate images

21

Patient does not have a skin injury

3

Referral inappropriate or ineligible

3

Effective Use of Resources (EUR) – procedures of limited clinical benefit

Stockport has the highest spend for:

Procedure

Ranking

Bunion

9/10

Benign skin lesions

8/10

Dupytrens

8/10

Ganglion cyst

9/10

EUR – Procedures of

Limited

C

linical

Benefit

Potential savings if the Stockport were in line with the GM average

EUR Policy (Where Stockport performs above the GM average)

Q1/2 1819

actual activity

Q1/2 1819 total

actual costActivity if Stockport was 'average'

Cost using q1/2 average

Full year potential benefit of Stockport moving to average

Cataract

Surgery

1266

£893,067

996.4 3712,483

£361,169 Bunion Removal

46 £178,044

32.2 £124,502

£107,084

Rhinoplasty / Septoplasty /

Septo

-rhinoplasty

82

£117,403

66.7

£95,515

£43,776

Common

Benign Skin Lesions

151

£98,595

143.6

£93,738

£9,715

Tonsillectomy

83

£91,378

79.2

£88,288

£6,180

Dupuytren's

Contracture 49 £102,338 35.6 £74,310 £56,057 Varicose Veins57 £60,449 56.6 £59,999 £899 Drainage of the Middle Ear 93 £77,327 55.4 £46,096 £62,463 Ganglion Cyst Removal 30 £36,397 25.9 £31,371 £10,052 Hyaluronic Acid Injections 48 £23,558 36.5 £17,919 £11,278 Knee Arthroscopy8 £18,909 7.6 £17,846 £2,125 Correction of Dermatochalasis 24 £21,757 14.6 £15,109 £13,295 Surgical Revision of Scarring7 £7,208 6.8 £7,029 £358 Total 1944 £1,726,430 1557.0 £1,384,205 £684,450

Weighted population (based on CCG 18/19 allocations)

There are repeated episodes of ulceration / infection necessitating surgery OR If there are associated problems with hammer toes or pain under the ball of the foot (suggesting excessive foot strain as big toe is not functional) NOTE

:

Most bunions can be alleviated by modifying activities and / or shoes

Surgery has a LONG recovery time (up to six months for full recovery) Surgery carries a risk of complications, some of which may require further surgery Treatment for bunions is not affected by ‘severity’ so a ‘before it gets worse’ approach is not necessary

EUR – procedures of limited clinical

benefit : BUNIONS

Impairment of function or significant facial disfigurement, e.g. large lipomaRapidly growing or abnormally located (e.g. sub-fascial, sub-muscular)There is significant pain as a direct result of the lesionThere is a confirmed history of recurrent infection / inflammationThere is reason to believe that a commonly benign or non-aggressive lesion may be changing to a

malignancy

, or there is sufficient doubt over the diagnosis to warrant

removal

EUR – procedures of limited clinical

benefit : BENIGN SKIN LESIONS

Mild:No functional impairment, TFD< 45Treat conservativelyModerate:Some functional impairmentMCP contracture 30-60’ and PIP contracture <30’

May benefit from collagenase (painful) or needle fasciotomy (may recur)

2 week recovery

Severe:TFD >90’

May benefit from limited fasciectomy or dermofasciectomy (less chance of recurrence)6 week recovery

EUR –

procedures of limited clinical

benefit : DUPUYTRENS

Usually, no treatment requiredCan be aspirated in primary care, but often recurMay respond to acupunctureAdvise daily massage with eg topical NSAIDsWrist ganglions often recur even despite surgerySurgery can lead to annoying scar tissue

Surgery only indicated for:

Severe pain,

Impaired functionSignificant concern over diagnosis (where u/s has been unable to characterise

)EUR – procedures of limited clinical

benefit : GANGLION CYST

Approx. wait time is 4-6 weeksCentral Stockport location – Choices centreGP referrals or walk-ins

Community Services –

Community Gynaecology Service

General Gynaecology Heavy periods, IMB, PCB , small fibroidsPMS, PCOS, DysmenorrhoeaRemoval of cervical polyps

Symptomatic

ectropion

Ring pessary

changes (repeat)Difficult smearsDirect listing for sterilisation, hysteroscopy, thermal ablation, colposcopyFamily PlanningGP referrals and

walk–ins

Difficult

coil fits, removals (LA injection, scans)

Complex

LARC procedures- double uterus, fibroids, repeat coil expulsions Removal

of deep implantsBleeding problems with IUS/IUD

Community Services – General Gynaecology/Family Planning

First point of contact for all primary urinary incontinence and faecal incontinenceOffer includes:Categorise incontinence – stress / urge / mixed Check MSU + treat UTI if indicated Examine to r/o other pelvic pathology Concomitant symptomatic prolapse – offer

pessary

treatment / pelvic floor physiotherapy

Asymptomatic prolapse – no treatment necessary Life style advice regarding fluid modification, weight reduction and smoking cessation

Information on pelvic floor exercise UUI – try 1st line anticholinergics / Mirabegron If postmenopausal – prescribe vaginal estrogen. Exclude / treat constipation

In

elderly – assess mobility & review medications

Community Services –

Community Continence Service

Patient Education – >55 painful knee education sessions

New initiative from SomersetLed by specialist dieticiansAvailable for IBS, low FODMAPS dietPatients self register via emailCan access webinar when it suits themFREE and QUICKNB: Patients are advised they can self refer to dietician using referral form – this is not available in Stockport as service is based in Somerset

gastro.webinars@nhs.net

Patient Education –

Gastroenterology Webinars

Patient Education – Gastroenterology Webinars

Recommended by NICE as a better alternative to FOBtLocal lower GI cancer pathway board recommendation for:

Patients

without

rectal bleeding and:

>50 with unexplained weight loss or abdominal pain>60 with non Fe-deficiency anaemia

Detects human haemoglobin so not affected by diet

Specific for lower GI blood loss

Sensitivity – 92%

Negative predictive value – 99.4-100%

Cost - £10

To date – 80% of requests have a negative result so referral potentially avoided

Faecal Immunochemical Testing (FIT)

Thank you

Any Questions